What remains to be seen is how the virus — and perhaps more importantly, our immune system’s response to it — will affect the health of people long after infection, even in mild cases. This once-in-a-century pandemic that has already killed millions across the globe could leave hundreds of millions more with chronic conditions varying in acuity.
“Not only is the viral infection bad for some people, but the subsequent body’s reaction to the viral illness in many people is remarkable. I personally have never seen anything like it,” said Dr. Philip Adamson, chief medical officer of Abbott’s heart failure business. “I’ve lived through and trained through the AIDS epidemic and learned a lot about viral pathophysiology, but what this does in certain people is amazing, and amazing that it only does it in certain people. … Every organ is susceptible.”
In an interview with Medical Design & Outsourcing, Adamson discussed COVID’s potential long-term cardiovascular impacts, medical devices and components likely to be in greater demand in the decades ahead, and how the industry should think about design and diversity in our new reality.
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The following conversation has been lightly edited for space and clarity.
MDO: What are you seeing now with COVID?
Adamson: What we call myocarditis associated with COVID-19 severe disease is somewhat rare, but the incidental damage due to this inflammatory response is pretty common. Patients come in many times with elevated levels of troponin — a marker of heart damage — but it’s not in a pattern that would reflect true overt focus on the heart as the centerpiece of the inflammatory response. It’s almost like an innocent bystander. Then the lungs. Lung circulation — the interface where oxygen and carbon dioxide exchange in the lungs, intricately woven with the heart — lungs and that circulation is where I think we see a lot of the ill effects of respiratory damage as a result of this illness. That’s probably one of the major areas in the future where we’re going to see residua. Those who survive severe disease very clearly have lung damage that decreases the effectiveness of the exchange of gases in lung circulation. As a result, you develop this new concept of lung failure, and it leads to a knee-jerk reaction to put a tube down the throat and breathe for the patient. But the breathing response and drive is probably not the problem. The problem is when you get air into the lungs, it can’t get into the bloodstream. We have now recognized the role of extracorporeal membrane oxygenation, or ECMO, which you can think of as dialysis for the lung. You wind up having that as a mainstay of therapy, and there’s early data to suggest that mechanical ventilation and intubation may not be helpful. There’s some evidence and some people who believe that it may be harmful with the barotrauma that’s associated with trying to force the air into the bloodstream and that it’s best just simply take the blood out, oxygenate it and put it back in the system. Unfortunately, ECMO machines aren’t everywhere, and it is a fairly labor-intensive process right now, but as we move forward, we all anticipate the development of longer-term interstitial lung disease resulting from the inflammation of the acute illness. That interstitial lung disease tends to be progressive, and over time we believe that there will be an increase in the number of people with end-stage lung failure that would require some level of therapy, whether it be ECMO longer-term or transplant. Those are issues that we are grappling with now. Providing that lung dialysis, the ECMO process, in a way that can long term support a patient is where we need to be when this result of the pandemic starts to hit clinical reality.
MDO: How do you see COVID changing demand for sensors and monitors?
Adamson: This is a very resource-dependent process, not only for ECMO, but also for transplant. We have to be careful to understand which patients should progress to what intervention over time. I think there’s a lot of opportunity for pressure sensing and for metabolic biomarker sensing. For example, lactate sensing, a reflection of how oxygen’s getting to the tissues and to the organs. Other biomarkers that can be continuously measured are going to be important to incorporate into that data stream. We’re going to have to make sure that we always have in the end game the thought process that we’re turning data into information, and that information has to be actionable in directing our efforts clinically to make the patient better.
MDO: Are there cardio products at Abbott and elsewhere that will be in greater demand as we get a few years out from the initial onset of COVID?
Adamson: We’ve talked about lung failure. I believe heart failure likely will go up as well. There’s this long-term idea that what we call nonischemic dilated cardiomyopathy — where the heart’s not damaged by blockages in the heart arteries, it just gets bigger and gets weaker over time — is probably based on the immune system chronically, slowly damaging the heart over time. And that’s probably from a sensitization of some people’s immune system to troponin C, what we measure to diagnose heart attacks. It’s really only found in the heart muscle, so if the body sees that circulating it could interpret that as an antigen that it needs to attack. That immune response slowly damages the heart over time. That can cause a dilated cardiomyopathy of unknown etiology. We are concerned. There’s some early, early, early evidence that would suggest that the heart is at risk for that in patients. There’s some suggestion that it’s in patients who don’t have severe disease that require hospitalization. We just don’t know. I’m not an expert in the future, but I do see that there is an increased probability we will see more heart failure. As that progresses to end stages, as that needs to be monitored, at Abbott many of our portfolios like MitraClip, CardioMEMS, CentriMag, and HeartMate 3 will be called into action. Ten years ago the American Heart Association suggested by 2030 we’ll see a doubling of heart failure prevalence. This is only going to make it even more prevalent and all of those standard therapies that we have for people with heart failure will be in bigger demand.
MDO: The pandemic caught just about everyone flat-footed and we’re still seeing shortages of materials and components like resins and semiconductors. How can we prepare for COVID-related demand in the years ahead?
Adamson: I’m no supply chain expert, but based on the interactions I have with those in our company who are, I think we have to just simply step back and say, “This is our norm now.” I don’t know how we catch up, honestly. We’re talking about rare metals, we’re talking about fundamental pieces that go into the fundamental working blocks of equipment. And we have to be really svelte on our feet to be able to both acquire components and be actively thinking about alternative components that can replace those that we envision will be in short supply. I don’t see an increased demand helping this at all, and I personally don’t see a lot of resolution of the supply issues in some of the components that we have in the past felt were always going to be there.
MDO: Any advice for medtech designers and engineers on how they should be thinking differently about their jobs with COVID and the effects on the heart and lungs?
Adamson: Always think about how to fundamentally replace things that are going to be in short supply, how you can achieve the same electrical connections, electrical processing, with different components. … Battery technology still lags other technologies in terms of size as well as long-term functionality. We’re all waiting for that major breakthrough for battery technology to really take the next step in medical devices. We’re volumewise constrained by batteries in pretty much everything we do.
MDO: With COVID disproportionately hitting minority groups and less affluent communities, how do you view this opportunity to improve how medtech can help historically underserved populations?
Adamson: Healthcare disparity in general, independent of COVID, is ingrained in the system and deadly. It causes people to die. You can go, for example, to Louisville, Kentucky, and people living in ZIP codes 5 or 10 miles away from each other have a 15-year difference in lifespan. And that’s not because they walk out and get shot. It’s because of disease. It has such deadly consequences that it requires us to think about it all the time. It starts with how we represent people in clinical trials, goes into how we implement in first adopters of new novel interventions, all the way to how do we facilitate healthcare in an environment where people have a hard time buying dinner? It’s systemic, and it’s something that we at Abbott have not only recognized but are working very hard to improve our representation in clinical trials and to train people to provide research and therapies to underserved populations. We are tacking this from the comprehensive strategy that we can’t boil the ocean. We can’t necessarily change the world, but we can change our world. And we are. We’re changing how we perform clinical trials, how we include patients, how we require inclusion for gender and race. We’re funding training programs to encourage African Americans, for example, to become physicians and then researchers. if you look at the NIH, less than 5% of investigators funded are of African descent, and you look at investigators in clinical trials it’s about the same, maybe 10% or less are African American. When you have a population that doesn’t trust the system, looking at someone who doesn’t look like you just amplifies that mistrust, and it becomes very difficult. I learned it in the Native American population in Oklahoma. Tribes in Oklahoma have the same death rate after myocardial infarction as Caucasians did in 1978. Native Americans don’t have heart failure necessarily as a major problem because they die from myocardial infarction. So it is pervasive, and we have to seriously consider how do we provide healthcare to people who deserve access to the innovations we have, not just for an elite group. … Going forward with COVID-19 and the post-pandemic sequela, it’s going to require us to have that same mindset, but not limiting it to the things that touch COVID.
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Adamson spoke with DeviceTalks in December 2021, offering an explanation of CardioMEMS to give a vivid portrait of how patients live with heart failure.